11 Communication Skills Training in Oncology: It Works!

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Summary

While the previous chapter by L. Fallowfield and V. Jenkins focuses on different communication skills training (CST) concepts currently being utilized, this chapter reviews and comments the scientific evidence of the impact of CST on improving communication skills. The aim of this chapter is not to provide a complete review of the evidence—this has already been done in systematic reviews—but to discuss the scientific evidence and reflect on the available results and relevant topics for further investigations.

11.1 Rationale for CST in Oncology

Communication skills training (CST) is based on the assumptions that (1) communication with patients requires specific skills, (2) these skills are relevant, and (3) such skills can be improved by training.

Communication with patients is not restricted to providing medical information. A medical consultation consists of cognitive, emotional, and relational aspects and requires specific skills, especially in oncology, since complex information is provided and vital decisions have to be made (Ong et al. 1995, 2000). Important differences with regard to communication skills have been observed among oncology clinicians: For example, some clinicians utilize avoidance strategies, such as denial of patients’ emotional suffering by focusing on medical information only; others re-

spond empathically to the patients’ cues and also discuss emotional and social aspects of disease (Guex et al. 2002; Wilkinson 1991). The important communicational variability observed, one can assume—and this has been confirmed by scientific and clinical observations—that specific communication skills are required in clinical practice (Fallowfield et al. 1998).

The relevance of communication in oncology has also been confirmed: Poor communication increases a patient’s psychological distress (Ford et al. 1996; Lerman et al. 1993; Razavi et al. 2000) and hampers his quality of life, adjustment to ill- ness, and adherence to treatment (Razavi et al.

2000), and may lead to dissatisfaction and increased risk of litigation (Ford et al. 1996; Loge et al. 1997). In addition, poor communication also has a negative impact on stress of the medical staff and increases burnout (Fallowfield 1995;

Ramirez et al. 1996).

Finally, effective communication skills are not just inborn qualities or a simple by-product of the professional experience (Fallowfield et al.

1998; Maguire et al. 1996); it has been shown that they can be modified and improved by specific training programs (Fallowfield et al. 1998, 2002, 2003; Gysels et al. 2004; Jenkins and Fallowfield 2002; Maguire et al. 1996).

CST is time-consuming and costly; it requires a high degree of motivation and induces a con- siderable stress in participants, since CST uses techniques that are confronting, such as feedback to participants about their videotaped interviews with (simulated) patients. Since communication is a central element in oncology, such an effort

11 Communication Skills Training in Oncology: It Works!

F. Stiefel, N. Favre, J.N. Despland Recent Results in Cancer Research, Vol. 168

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is justified as long as this training proves to be effective. A meaningful scientific investigation of CST is therefore necessary. Such research is challenging, yet not impossible to realize. The following paragraphs aim to discuss the results and limitations of current research on CST in oncology.

11.2 Objectives

and Setting of CST

Different forms of CST have been developed, addressing different populations such as medical students (Klein 1999), transplantation spe- cialists who deal with sensitive issues like organ donation (Fitzgerald et al. 2004), or oncology clinicians (Fallowfield et al. 1998, 2003; Jenkins and Fallowfield 2002; Wilkinson et al. 2002). In Switzerland, CST has become mandatory for physicians who wish to specialize in oncology (Hürny 2000). The objectives of CST are shaped by the professional and cultural background of the trainers and participants. Some trainings focus on breaking bad news, others on patient needs assessment, empathic response, or relational aspects of communication (Gysels et al.

2005). Most often, different objectives co-exist and many of them are interrelated. For example, to respond with empathy to a patient’s distress is only possible if the relational aspects of a consultation are perceived, if the patient’s needs are acknowledged, and if the understanding of the situation includes the psychological aspects. And a clinician who responds empathically will also deliver bad news in a way that makes the patient feel contained and understood. Nevertheless, to define specific objectives of CST is important, especially for educational purposes; however, in clinical reality, these objectives cannot be sepa- rated, since they are part of a whole.

With regards to participants, CST most often addresses nurses and physicians; some are mono- disciplinary and others interdisciplinary, and the number of participants varies considerably (Gy- sels et al. 2005). Interdisciplinary training has the advantage of increasing mutual understanding between members of the medical staff—misun- derstandings being a common source of confu-

sion and mismanagement with a negative impact on the patient. As long as the number of nurses and physicians is balanced, interdisciplinary training seems to have a clear advantage. In some cultural contexts, however, it may be that physicians are still reluctant to work on such sensitive issues together with nurses. We have found that nurses often respond more adequate to patients’

distress than physicians, while the latter often have a greater ability to structure the consultation. No study has yet addressed the question of whether a mono- or interdisciplinary approach produces different outcomes. The number of participants is also a crucial variable. We work with small groups of 8–10 participants; and feedback on videotaped interviews with simulated patients is provided in subgroups of 4 participants (Favre et al. 2006). One can easily imagine that this setting allows for a much more secure and individualized atmosphere than training programs with larger groups. In studies evaluating CST in oncology, groups ranged from 3 to 40 participants (Gysels et al. 2005). The literature still lacks data on cost-effectiveness of CST with regard to the number of participants.

Professional backgrounds of teachers and teaching methods also differ. CST teachers in oncology are usually psychiatrists or psychologists.

While the above-mentioned systematic review did not identify the professional background and qualification of teachers, we firmly believe that only experienced psychiatrists or psychologists working in consultation-liaison psychiatry or psycho-oncology should provide such training.

The key to success for many participants involves being confronted with their communicational difficulties in a way that respects their narcissis- tic vulnerability. The credibility of the teachers depends on their capacity to build a construc- tive and safe atmosphere, to react adequately to group phenomena, to manage “difficult” participants and their profound knowledge of the professional environment of the participants.

Duration of CST is another factor influenc- ing outcome. Training sessions evaluated scien- tifically (Gysels et al. 2005) were either provided in workshops of a few days duration or in sessions spread over a period of a few weeks; there is certainly a time limit below which the effect

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of a CST will not be satisfactory. The benefits of booster sessions, for example, have been demon- strated (Razavi et al. 2003).

The fact that there are various types of CST, which differ with regard to objectives, duration, number and professional background of participants, and qualification of teachers, does not facilitate their scientific evaluation. The level of evidence of their evaluation varies, with only 13 studies (out of 47) meeting the inclusion criteria of a systematic review (Gysels et al. 2005): Only four were grade 1a randomized controlled trials;

most of the other studies were based on a single- group pre/post test design.

11.3 CST: What Works?

Most CST in oncology utilizes an interactive approach focusing on role-play, feedback to videotaped or audiotaped interviews with simulated patients, and small-group discussions of case presentations. The training usually lasts several days, sometimes followed by individual supervision and booster sessions.

The heterogeneity of CST is problematic from a scientific point of view. It is difficult to compare the studies or include them in a meta-analysis.

From a clinical point of view, however, stan- dardization is counterproductive and hampers learner-centered methods, most effective in post- graduate education. CST seems to be effective if individualized and if the training corresponds to the clinical reality. What is a difficulty from the scientific point of view is therefore a necessity from an educational point of view and should not lead to the wrong conclusion that studies of CST are less “scientific” or that only CST utiliz- ing highly standardized, evidenced-based ap- proaches should be implemented. On the con- trary, such CST may be inappropriate, since they neither reflect real world conditions, nor are they participant-centered.

Another problem with the studies investigat- ing CST concerns the fact that a CST session has various effective elements. This may be il- lustrated by a few examples based on views of these training methods from different psychological perspectives. Participants learn new ways

of communication by means of case discussions, role-playing, and feedback to videotaped interviews. From a cognitive point of view, one may argue that case discussions modify the mental representation of how to interact with patients and introduces a broader set of possible responses and thus a more patient-centered approach. From a behavioral point of view, one may argue that role-playing enables participants to experience new ways of communicating and thus a more patient-centered approach. From a psychodynamic point of view, one may argue that feedback increases self-awareness of the participants’ own communication style, identi- fication with experienced teachers and peers, a growing understanding of relational aspects, and thus a more patient-centered approach.

While from a scientific point of view the co- existence of different “active” elements makes it difficult to understand how CST works, from an educational point of view it is well known that only training based on different didactic ap- proaches combining theoretical knowledge with practical exercises is effective. Methods based on a unique didactic approach are condemned to fail, since participants have different learning styles and benefit from various educational com- ponents. What seems problematic from a scientific point of view is therefore a necessity from an educational point of view.

11.4 CST in Oncology:

Outcomes

Different outcomes of CST have been identified:

(1) behavioral assessment, (2) patient outcomes, and (3) participants’ self report. Behavioral assessment is based on coding of various aspects of communication, such as speaking time of the simulated patient, interruptions by the physician, or number of open questions. The aim of behavioral assessments is to evaluate if patient- centered communication can be improved. Pa- tient-outcome studies evaluate the impact of CST on the patient; they are based on patients’ judg- ment (e.g., satisfaction, comments, or feelings).

Self-report studies rate the perceived change of participants (skills, ability to apply new skills, or

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confidence in communication). These three different outcome measurements have been utilized alone or in combination. All of them have advan- tages and disadvantages.

In behavioral assessment, video- or audiotaped interviews with simulated or “real” patients are coded and scored by trained and indepen- dent raters using standardized methods (Booth and Maguire 1991; Ford et al. 2000; Roter 2002;

Wilkinson 1991). While this method produces statistically meaningful categories of desired and undesired training effects, thus reflecting a cer- tain objectivity, this approach may also be problematic. Some aspects of communication that are not coded by these methods will not be analyzed;

for example, nuances and non-verbal signs, which provide meaning and foster therapeutic alliance, are omitted in the evaluation process.

In addition, even if a given behavior falls into a

“positive” category of the rating system, it may not be adequate in specific medical situations:

For example, if a patient is anxious and over- whelmed, it might not be adequate to challenge him with open questions and to focus on his emotions; instead, it would be more appropriate to provide relevant information and guidance.

Patient outcomes, the second category of measurements utilized (Faulkner et al. 1995;

Heaven and Maguire 1996), evaluate the direct impact of training on the patient. This seems, at first glance, the most elegant method to evaluate CST, since their ultimate objective is to improve communication with the patient. While this approach may be clinically meaningful, it is difficult to realize from a methodological point of view.

In a pre/post design, different patients or different clinical situations have to be evaluated. If different patients are included, the impact of the training may be biased by patient selection. If the same patients are included, the clinical situations have evolved, presenting different challenges for the patient and the clinician; in addition, a most important variable of communication, the physician–patient relationship, has been fostered and thus a beneficial outcome may be its direct consequence. Randomized clinical trials, on the other hand, include different clinicians, different clinical situations, and different patients, all of which represent important confounding vari-

ables and imply that a high number of subjects have to be included in a study.

Finally, participants’ self reports on chang- ing attitudes (Fallowfield et al. 1998; Jenkins and Fallowfield 2002; Klein 1999) are measured.

However, increased awareness does not imply a change in clinical practice. Participants’ self reports may be influenced by the participants’ social desirability and their need to show that their efforts were beneficial. One interesting approach is based on the participants’ capacity of self-criticism when reviewing their interaction with a patient (Wilkinson et al. 1998, 1999, 2002), which may reflect an increased awareness when inter- acting with patients. Again, this approach does not provide evidence that communication really improves, and clinicians who are generally self- critical may bias the results.

Another important question is whether a benefit of CST is maintained over time. For example, the Swiss model (Hürny 2000) provides each oncology clinician with individual supervision 4–6 times over 6 months after the initial CST of 2 days. These sessions are utilized by participants in various ways. Some participants present re- current difficulties with patients; others discuss emotionally charged situations. A few elaborate on their own psychological difficulties, which sometimes lead them to initiate psychological treatment. From our point of view, these individual sessions certainly help to induce change.

There is a lack of studies evaluating the benefits of follow-up and booster sessions and the long- term effect of CST.

Taking into account the difficulties associated with the scientific evaluation of CST, a systemic review (Gysels et al. 2005) concluded that studies based on behavioral assessment achieved positive outcomes for different parameters such as open questions, empathy, responses to patients cues, control of the interview, and exploration of patients’ feelings. Studies assessing patient outcomes failed to demonstrate an effect. Studies based on physician’s self rating showed changes of attitudes, an increased sense of responsibility when telling bad news, improved confidence and satisfaction, as well as enhanced self-criticism when listening to audiotapes of consultations.

Some of these studies showed maintenance of

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improvement after several months, others only reported post-training improvements but not long-lasting effects.

11.5 CST:

How Does It Work?

One of the unanswered questions regarding CST is how improvement is achieved. Up to now, studies only addressed the question of whether CST had an impact or not. However, as with any other intervention, it is also important to understand how such training induces change.

Probably one of the most powerful variables of variance in outcome is the participant himself.

We observe that some participants show an im- pressive increase in their communicational flex- ibility, leading to skilled patient-centered consultations, while others seem not to benefit from CST.

An understanding of how CST works may lead to the conceptualization of more specific training sessions, focusing on elements of communicational progress. If one considers CST as a psychological intervention with an educational objective, one wonders why such training includes professionals without restrictions. For any other psychological intervention, indication is an important issue. For example, behavioral interventions may be most effective for some clinical problems such as phobic behavior, but they are not suitable for persons who wish to understand how biographical circumstances influence their ways of relating to others. Since CST sessions are psychological interventions aimed at inducing change in the interactions participants have with their patients, inclusion criteria are important.

A brief case report from one of the communication skills seminars conducted in Switzerland illustrates this point.

Upon reviewing his videotaped interview with a simulated patient, a 38-year-old male physi- cian suddenly cried out, “It’s not me, it’s my dead brother on the tape,” broke into tears and ran out of the room. After a brief discussion with one of the teachers, he returned back to the session and was motivated and able to continue to review a short part of the video without misinterpretations.

The distress of the situation and the painful remembrance of his brother’s death induced in this vulnerable man a brief psychotic episode.

This example illustrates that CST can have negative impacts and that inclusion of participants should be based on an indication, as with other psychological interventions. Before defining in- dications and inclusion criteria, we should understand how CST works.

11.6 Psychodynamic Hypotheses Concerning CST

None of the published studies has addressed the question of how CST induces change. We will therefore present some preliminary results of a current study of our group addressing this issue.

The aim of this paragraph is not to discuss methodological aspects of this project, but to illustrate a possible scientific approach.

Our interest focuses on the question of how oncology clinicians handle emotionally charged consultations. According to the psychodynamic approach, an individual faces distressing emotions by mobilizing defense mechanisms, which serve to protect him. We hypothesized that emotionally charged consultations trigger clinicians’ defense mechanisms, which are more or less adaptive; if not adapted, they may hamper communication, empathy, and recognition of patients’ suffering. Our main hypothesis is that CST modifies defense mechanisms of participants, leading to a more adaptative, patient-centered communication style. In a pilot study, verbatim transcriptions of videotaped interviews with simulated patients were evaluated before (n=10) and after CST (n=10) with the Defense Mecha- nism Rating Scales (DMRS) (Perry and Cooper 1989 ; Perry 1990). A wide variety of defense mechanisms were observed (Favre et al. 2006).

The less adapted and immature defense mechanisms, such as projection or denial, globally de- creased after CST, while the general defensive level improved. We concluded that a wide variety of defense mechanisms are operant in oncology clinicians facing challenging interviews, and that defense mechanisms may be modified by CST

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(Favre et al. 2006). Since these results could par- tially answer the question of how CST works, a more comprehensive and controlled study is currently conducted.

11.7 Conclusions

A review of the scientific literature on CST in oncology reveals a fascinating field of research, most relevant for oncology practice. While evidence exists that these training sessions induce change toward more patient-centered communication, several methodological difficulties associated with these studies persist. Most important, a variety of confounding variables exist, and there is a lack of understanding of how CST induces change. Despite the fact that the participant himself is probably the most important variable of variance in outcome, none of the published studies has investigated this topic to date. Research on medical communication and CST is only emerging. Hopefully, the clinician caring for patients will increasingly become a topic of interest and scientific investigation. Practicing medicine implies the encounter between (at least) two persons, namely the patient and the clinician; it is rather curious that up to now the overwhelming majority of scientific efforts of medical psychol- ogy has only focused on the patient.

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